Role of Computed Tomography and MRI in Detecting Extradural Haemorrhage after Trauma - Assignment Example

RADIOGRAPHY QUESTIONS The role of computed tomography (CT) and magnetic resonance imaging (MRI) in detecting extradural haemorrhage (EDH) after trauma. (500 words) Extradural haematoma (EDH), which is also known as epidural haematoma can be referred to a situation in patients where there is a collection of blood, forming between the inner surface of the skull and the outer layer of the patient’s dura (Blauth et al., 2006). The conditions come about after patients have experienced various forms of trauma, including heavy fall, vehicular accident and sudden kicks. Once the condition comes about, it is considered to be very serious and requiring urgent diagnosis to know exactly what is happening in the head. Consequently, the work of the radiographer comes to play in determining what is going on. Studies and professional practice has showed that two major approaches that could be devised in doing this are computed tomography (CT) and magnetic resonance imaging (MRI). Broder and Warshauer (2006) noted that each of these two methods have their own unique merits and roles that they play in detecting EDH, especially when it comes to detecting the pathophysiology of the condition, which focuses on knowing the exact source of bleeding in the head. According to Cannon, Silvestri and Munro (2009), during EDH, skull fracture is a very common situation that easily occurs. It is further indicated that the success with accurate detection and decision making on the skull fracture can lead to overall effective interpretation of the condition. Meanwhile, Gallagher and Browder (1968) in a study indicated that CT is most effective in detecting skull fractures, most especially when it comes to fracture at the skull base and the lesions of osicles. In a related study, Hardy and Boynes (2003) also stressed on the important role that CT plays in undertaking systematic approach to EDH. A systematic approach to EDH is a situation whereby very specific aspects of the condition are identified and critically studied as part of the imaging process. CT has consequently been known to play an important role when it comes to such aspects of EDH that has to do with airspaces, bones, and blood. Hounsfield (2006) noted that in CT, normal airspaces are seen to be black on brain and bone windows. This means that any other colourisation gives indication of a problem. The PACS of CT can also be set to bone windows to enable internal assessment of any form of fractures within the internal structure of the bone. Last but not least, CT is important in EDH in knowing the age of blood product collected during a haemorrhage. For patients with EDH, MRI has also been found to have several roles in helping radiographers give a perfect interpretation of injuries. idrawdigital (2009) noted for example that the role of MRI has been found to be superior when it comes to distinguishing chronic subdural hematomas from hygromas. It would be noted that clinical treatments given to patient with subdural hematomas is different from what is given to those with hygromas. It is for this reason that this role of MRI can be considered to be very critical. Again, MRI has been found to produce much superior quality when it comes to visualising non-hamorrhagic contusion in 15 to 21 lesions (Snow, Zimmerman, Gandy and Deck, 1986). Even though EDH concerns the occurrence of a haemorrhage, Kleiman and Shelton (1997) emphasised that the need to have clear visualisation of non-hamorrhagic contusion lesions is necessary for detailed examination and knowing related effects of the EDH. What is more, MRI’s role has been found to be very useful when the issue of time comes to play. This is because MRI has been found to be very effective for injuries which are more than 72 hours old, as the procedure is poor for acute subarachnoid. Is the most effective imaging technique being used for the tangential patella imaging projection in the clinical practice? (500 words) Patella fractures and other injuries have been noted to be one of the commonest forms of problems reported to clinicians for professional management each day (Lamoureux, 2013). To make the most out of clinical practice, the need for imagining projection aimed at studying and understanding the exact extent of damage is relevant. Writing on why it is very important to undertake such radiographic procedures as tangential patella imaging projection to have a better understanding of the patella fraction, Lufkin, Smith, Matticks and Brunette (1998) indicated that patella fractures come in different types and each require different forms of treatment. It is for this reason that for effective clinical practice to take place, radiologists have to play their part in bringing out the most exact type of patellar fracture that is being dealt with. Writing on the types of primary patellar fractures that a typical tangential patella imaging projection can reveal, Lamoureux (2013), mentioned transverse, vertical, marginal, and osteochondral fractures. But for all these to be done effectively, the need to use the most effective imaging technique has been admonished. Merino-De Villasante and Traveras (2007) indicated that the most effective radiographic imaging techniques that can be used in the case of tangential patella imaging projection in the clinical practice are computed tomography (CT) scanning, bone scanning, and magnetic resonance imaging (MRI). Each of these have however been noted to be effective in meeting very specific needs for patients. For example, CT scanning is said to be necessary and effective in cases where no visuals can be created on radiographs (Lamoureux (2013). This means that ordinary radiographs cannot be considered effective for tangential patella imaging. What is more, CT has been noted to be specifically useful when the need to locate the exact position of fracture fragments is necessary. What is more, for patients whose situation requires the need to identifying the localisation of intra-articular loose bodies, using CT is considered very effective. Mirvis et al. (1990)) actually mentioned that one merit that makes CT very effective and useful in this sense is its ability to prevent delay in treatment as its outcomes are virtually instant (Owen, Hickey and Finlay, 2005). Bone scanning has also been noted to be useful and effective in very specific instances and cases. Lamoureux (2013) emphasised for example that there are instance where in clinical practice, fractures are suspected at the patella region by the radiologist but radiographic findings actually seem to be very normal. In such dilemma situations, bone scanning is considered very effective in confirming for the radiographer the existence of fractures. It is therefore for bone scan to confirm that the patella is normal before fracture can be ruled out. There is however some form of weakness with the use of bone scanning, as it cannot determine the accurate age of fractures at the patella region (Perron et al., 1998). Similarly, MRI can be used detecting fractures that were not indicated from ordinary radiographs. One advantage that MRI has over bone scanning is that it can be done very immediately without delays and does not come with the use of any forms of radiation (Rivas et al., 2008). MRI also gives much detail with bone-marrow and soft-tissue injury in great detail (Lamoureux, 2013). Which Imaging Modality is the Best for Diagnosing Occult Hip Fractures? (500 words) Hip fracture has been noted to be a relatively common situation that happens at a high rate per year. In most of these hip fractures, plain radiographs have been identified to be sufficient in coming up with diagnosis (Rooks, Sisler and Burton, 1998). The problem however is that it is not all the time that hip fractures are of the same kind and very simple. In some cases, what is known as occult hip fracture occurs. This is a type of hidden hip fracture where clinical findings undertaken gives indications of a fracture but such cannot be easily confirmed by radiographs (Cannon, Silvestri and Munro, 2009). Meanwhile, the hip is known to play very important role in the daily life of a person and so such cases of occult hip fracture cannot be allowed to go without the needed diagnosis to know what is actually going on within the injured position. This need brings to discussion various imaging modalities that can work best for diagnosing occult hip fractures. In the opinion of Schriger et al. (1998), there are several imaging methods that can be used in the Emergency Department (ED) context to diagnose occult hip fractures for the purpose of undertaking further and better evaluation of the situation. The only problem that is identified however is that each of the imagining methods comes with their own intrinsic limitations, making is very important for radiographers to select the best modality that comes with less or fewer intrinsic limitations. On the whole, three methods, which are computed tomography, scintigraphy and magnetic resonance imaging (MRI) are identified by Cannon, Silvestri and Munro (2009) to be effective in diagnosing occult hip fractures. Among the three methods named above, has been noted to be the best for diagnosing occult hip fractures, given the fact that it comes with fewer intrinsic limitations when compared with the others. There are also several imaging properties within the hip area that this method helps to bring out that the other methods have been found to lack considerably. For example Cannon, Silvestri and Munro (2009) indicated that due to the presence of hydrogen ions and their response effect to magnetic fields during the production of images of MRI, it is possible to identify various tissues and pathology, including fracture. This means that when MRI is used as the imaging modality for occult hip fracture, the possibility of fracture getting hidden is overcome to a very large extent. This is because there are subtle differences that concentrate not just on the fracture but also on various tissues and pathology. Meanwhile with knowledge of the tissues and pathology involved in a clinically suspected hip fracture is considered to be sufficient evidence for further clinical decisions to be taken. What is more, MRI is considered to be the most effective imaging method because it is able to deal with the issue of time. What this means is that no matter the age of the occult hip fracture, it is possible to have the MRI exposing bony trabecular disruptions (Schwartz et al., 2007). This way, the issue of fracture being hidden becomes overcome. Such bony trabecular would always be showed on T1 imaging as low-density dark bands as showed in the figure below. Source: Cannon, Silvestri and Munro (2009) Discuss methods used by Diagnostic Radiographers to reduce exposure dosage which received by neonatal patients and neighbouring babies in Neonatal intensive care unit? (500 words) Most certainly, the method and approach to radiography for adults cannot be the same as what is given to newly born babies and even other children. This is because such newly born babies have tissues that are very fragile and vulnerable because they are not well developed as what adults have (Snow et al., 1986). Because of this, the need for radiographers to use various methods to reducing exposure dosage which is received by neonatal patients and neighbouring babies in neonatal intensive care unit has been extensively emphasised in literature. One of these key and most emphasised methods is the use of task-specific dose reduction for neonatal imaging by using a CsI direct radiographic (DR) detector (Whaley, 2012). There are a number of DR detectors that have been used in different studies. One of these that has been identified to be very effective has been found to be Carestream cesium iodide DRX detector. When used for neonatal ICU imaging purpose, the Carestream cesium iodide DRX detector has been found to have very high dose reduction potential (Whaley, 2012). What is more enterprising is the fact that this method does not guarantee dose reduction in just a single feature or area of neonatal exposure but in as many as three, which are named as carina, endotracheal tube tip (ETT) and largest pneumatocele. Using a fundamental basis of 15 to 20 µSv for chest exams as an effective dose for neonatal radiography, Whaley (2012) noted that task-specific methods like low-dose ETT can give both dose reduction and high diagnosis quality. In a related study, Whaley (2012) elaborated on the use of multiple or accumulated methods in dose reduction for neonatal ICU usage. In this, the use of low-kVp imaging in addition to rib-contrast suppression (RCS) were combined and used to examine the effect they would have on dose reduction. Indeed, the study showed that not only does this combined method made up of low-kVp imaging and RCS guarantee dose reduction but also improve and maximise the appearance of lesions in chest x-rays. Consequently, Schwartz et al. (2007) indicated that the fear that trying to reduce dose in neonatal cases will amount to reduced quality of images is not a reality. Using the same cesium iodide Carestream DRX detector mentioned earlier, Whaley (2012) gave the assurance that such method aids in maximising anatomy contrast and lesion visualisation when lower kVp is combined with RCS. Another method that has long being used is exposure index (EI) standard, which is used to assess the potential for reducing radiation (Rattan and Cohen, 2013). In such an instance, a comfort pad is placed underneath the baby with the purpose of absorbing x-rays that have already passed through the baby (Rooks, Sisler and Burton, 1998). Rattan and Cohen (2013) however debated that the real efficacy in reducing dose is for radiographers to remove the comfort pad, as these comfort pads cause high attenuation of the radiation beam once it goes from the chest phantom. In effect, removing the comfort pad before exposure takes place would be noted as the best form of EI standard for reducing radiation in the neonatal setting. References Blauth, M., Schmidt, U., Otte, D. et al. (2006) Fractures of the odontoid process in small children: biomechanical analysis and report of three cases. European Spine Journal 5 (1), 63–70. Broder J, and Warshauer DM. (2006). Increasing utilization of computed tomography in the adult Emregency Department, 2000-2005. Emerg Radiol. 2006 Oct; 13(1):25-30. Epub 2006 Aug 10. Cannon J, Silvestri S. and Munro M. (2009). Imaging Choices in Occult Hip Fracture. J Emerg Med. 2009;32(3):144-152. Gallagher JP and Browder J. (1968). Extradural hematomas: experience with 167 patients. J Neurosurg; 29:1. Hardy A. and Boynes F. (2003). Paediatric Radiography. Blackwell Publishing: Bradford. Hounsfield GN. (2006). Historical notes on computerized axial tomography. J Can Assoc Radiol. Sep; 27(3):135-42. idrawdigital (2009). Drawing Tutorial: Anatomy and Proportions #2 Adult & Child Proportions. http://www.idrawdigital.com/2009/01/drawing-tutorial-adult-child-proportions/ Kleiman, P.K. and Shelton, Y.A. (1997) Hangman’s fracture in an abused infant: imaging features. Paediatric Radiology 27 (9), 776–7. Lamoureux C. (2013). Patella Fracture Imaging. [Online] Available at http://emedicine.medscape.com/article/394270-overview [June 29, 2014] Lufkin KC, Smith SW, Matticks CA and Brunette DD. (1998). Radiologists review of radiographs interpreted confidently by Emregency Physicians infrequently leads to changes in patient management. Ann Emerg Med. 31(2):202-7. Merino-De Villasante J, and Traveras JM. (2007). CT in caut head trauma. Am J Roentgenol; 6;12:765. Mirvis SE, Wolf AL, Numaguchi Y, et al. Post-traumatic cerebral infarction diagnosed by CT: prevalence, origin, and outcome, Am J Neuroradiol 1990,11:355. Owen, R.J., Hickey, F.G. and Finlay, D.B. (2005) A study of metatarsal fractures in children. Injury 26 (8), 537–8. Perron AD, Huff JS, Ullrich CG, Heafner MD and Kline JA. (1998). A multicenter study to improve Emregency Medicine residents recognition of intracranial emergencies on computed tomography. Ann Emerg Med. 1998 Nov; 32(5):554-62. Rivas JJ, Lobato RD, Sarabia R, et al. (2008). Extradural hematoma: analisys of factors influencing the courses of 161 patients. Neurosurgery, 23:44. Rooks, V.J., Sisler, C. and Burton, B. (1998) Cervical spine injury in child abuse: report of two cases. Paediatric Radiology 28 (3), 193–5. Schriger DL, Kalafut M, Starkman S, Krueger M, Saver JL. (1998). Cranial computed tomography interpretation in acute stroke: physician accuracy in determining eligibility for thrombolytic therapy. JAMA. 1998 Apr 22-29; 279(16):1293-7. Schwartz, G.R., Wright, S.W., Fein, J.A. et al. (2007) Paediatric cervical spine injury sustained in falls from low heights. Annals of Emergency Medicine 30 (3), 249–52. Snow RB, Zimmerman RD, Gandy SE and Deck MD. (1986). Comparison of magnetic resonance imaging and computed tomography in the evaluation of head injury. Neurosurgery. 1986 Jan;18(1):45-52. Whaley J. (2012). RSNA Session Recap: Improve Image Quality While Decreasing Dose. [Online] Available at http://www.carestream.com/blog/?tag=patients-first [June 29, 2014] Rattan AS and Cohen MD. (2013). Removal of comfort pads underneath babies: a method of reducing radiation exposure to neonates. Acad Radiol. Oct;20(10):1297-300. Read More